The Transformation of the World (41 page)

It soon became clear that vaccination would wipe out the disease only if the entire population was compelled to undergo it. Countries with centralist traditions or modernizing authoritarian systems of rule were particularly quick to act. In 1800 Napoleon gave the go-ahead for the first vaccinations, and between 1808 and 1811 nearly 1.7 million people in France were immunized.
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Egypt under Muhammad Ali made vaccination compulsory, at least on paper, as early as 1818; the pasha sent teams of French doctors into the villages to vaccinate children and to instruct barbers in the necessary techniques. But the most important breakthrough came with the creation of a permanent health service in 1842, covering both the capital and the provinces.
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Things moved faster in Egypt than in Britain, where immunization became obligatory only in 1853 (more effectively in 1867)—until libertarian MPs opposed to any state compulsion managed to prevail on the issue in 1909, at a time when public debate was still raging in the United States about its advantages and disadvantages.
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Jenner's discovery soon traveled around the world, and Jenner himself received news about this from remote corners of the globe, including letters of gratitude from Thomas Jefferson and from the chief of the Five Nations in Upper Canada.
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European ships, previously notorious as vehicles of disease, carried cowpox lymph to many overseas countries, in an early example of the global diffusion of knowledge and problem-solving strategies. How was the vaccine transported? The best method was via infected human agents, and for this it was necessary to have a group of nonimmune individuals (often taken from an orphanage). A member of the group was infected, then the lymph pus was passed on to the next member, and so on; this ensured that there would be at least one virulent case on board when the ship reached its destination.

In 1803 the Spanish king Charles IV, an admirer of Jenner's, sent out an expedition with vaccine material to all the Crown's colonies. On its way from Buenos Aires, Chile, and the Philippines it put into southern China, where vaccine had arrived almost simultaneously from Bombay. In 1805 doctors at the East India Company settlement in Canton began to work with the vaccine, and in the same year literature on the subject was translated into Chinese. In Japan news of Jenner's discovery arrived in 1803; more was learned in 1812 from a Russian medical treatise that a Japanese prisoner-of-war had brought home with him. But vaccine was still lacking. The first batch reached Japan from Dutch Batavia only in 1849—an astonishingly late date in comparison with other countries.
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One should be wary, however, of a linear success story. For a long time the need to keep immune protection up to date was not understood. Unsuitable human carriers passed on other pathogens together with the vaccine; and many
governments failed to recognize the importance of
mass
vaccination. All this gave rise to major unevenness. German soldiers who marched off to fight in France in 1870 had almost complete protection from a dual vaccine, whereas a large part of the French army had none. Around the same time smallpox was flaring up again in various parts of the country. The Franco-Prussian War thus took place in the midst of an epidemic crisis, and the asymmetry of protection contributed to the eventual French defeat. The French army lost eight times more soldiers than the German to smallpox, and as many as 200,000 civilians may have died of it in France between 1869 and 1871. Moreover, French prisoners-of-war carried the disease with them to Germany, where the general population was much less protected from it than soldiers. A severe epidemic in the years from 1871 to 1874 cost more than 180,000 people their lives.
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The degree of smallpox protection did not at all reflect the level of economic development. Impoverished Jamaica, for example, was free of smallpox decades before wealthy France; inoculation had been practiced there since the 1770s, and Jenner-style vaccination since the turn of the century, making the largest and earliest of the British “sugar islands” a model in this respect. The colonial authorities created a special Vaccine Establishment, and by the mid-1820s smallpox had disappeared from Jamaica, to be followed a few years later by most of the other British Caribbean islands ahead of most other parts of the world.
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Ceylon, also an island under British control, would be smallpox-free by 1821 after a mass vaccination campaign. This was by no means the rule in Asia. In the giant subcontinent, outbreaks of smallpox occurred somewhere or other in every year of the century, the most dramatic being in 1883–84. In Kashmir vaccination only began in 1894. In Indochina, where the French colonial rulers showed less concern than the British did in India, smallpox proved especially stubborn.
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In Taiwan, which the Japanese annexed as a colony in 1895, the authorities carried out an effective mass vaccination campaign, and by the end of the century the island was more or less clear of smallpox.
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In Korea, the first Europeans who arrived in the formerly closed country in the 1880s found few people untouched by the disease; it had not been introduced to the peninsula from outside, and it was eventually eliminated under Japanese colonial rule in the second and third decades of the twentieth century.
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Although it was only in 1980 that the World Health Organization declared the world free of smallpox (the last natural case had occurred in Somalia in 1977), the breakthrough had been achieved in the nineteenth century. Where the disease lingered until the Second World War—and very rarely afterward—it was the result of government neglect, corrupt health administrations, or special epidemiological situations. The last epidemic in the West was recorded in 1901–3 in the United States. Sweden was the first country in the world to free itself even of endemic smallpox, in 1895. The disease was still deeply implanted in Africa and the Middle East on the eve of the First World War; only a small minority of those populations enjoyed vaccine protection.
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The great advances in immunization occurred there in the twentieth century.

The problems that had to be solved before whole populations enjoyed immunity were in principle the same throughout the world: it was necessary to overcome opposition, in Britain as in Africa (where people distrusted the colonial authorities); governments had to make vaccination compulsory and to carry out checks; and high-grade vaccine had to be available in sufficient quantity. These were tasks that required complex organization, and they were not always fulfilled better in Europe than in Asia. Disciplined societies were the most successful, but even among them there were differences. Hesse and Bavaria were the first German states to introduce smallpox vaccination, under Napoleonic influence in 1807, but Prussia—which protected its army so well—otherwise put its trust in the commitment of local doctors.
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Western and Indigenous Medicine

Colonial regions seemed to have at least a theoretical advantage insofar as new vaccination techniques were made directly available to them. In Africa, Ethiopia—the only noncolonized country apart from Liberia on the eve of the First World War—was the last to introduce Jenner's methods. Elsewhere vaccine arrived early on, but for a long time it was restricted to the ruling circles. In Madagascar, for example, where smallpox victims had traditionally been buried alive, the king had the royal family vaccinated as early as 1818, but he could not effectively protect the whole island, a nodal point of the slave trade.
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The procurement of vaccine from abroad was also a weak point in the otherwise successful reform policies of the kings of Siam. Only at the end of the century, later than in modest European colonies in Asia or the Caribbean, did government vaccination programs begin to get a grip in this independent country.
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Colonies—at least those considered important—therefore had relatively good chances. The authorities understood that they could kill several birds with one stone: strengthening the labor capacity of the colonial population while also gaining a reputation as colonial benefactors and helping to protect the mother country from infection.
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What role did scientific knowledge play in this? Here, too, we need to pay attention to chronology. The important breakthroughs happened only after the middle of the century. From the late 1850s onward, Louis Pasteur and Robert Koch discovered that certain diseases were caused by microbes, and in a number of cases they developed medical therapies. The first post-Jenner vaccine, however, appeared only in 1881, when Pasteur isolated the anthrax bacillus; then Koch found an antitoxin against diphtheria in 1890.
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Around 1900 medical science had only a few reliable drugs at its disposal—among them quinine, digitalis, and opium. Aspirin appeared on the market in July 1899. The twentieth century would be the great age of mass immunization against infectious diseases and of successes against bacterial illnesses with the help of sulfanomides and antibiotics. But one of the major achievements of the nineteenth century was a new insight into the underlying causes of inflammatory processes. From about 1880, the general use of antisepsis and disinfection reduced the incidence of mortality in
childbirth, but only in Western countries.
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The main contribution to the overall quality of life was in disease prevention rather than treatment—a trend reversal that set in with the new century. The generation that grew up in the West after the Second World War was the first in history not to live beneath the Damoclean sword of infection. In the United States, for example, the risk of dying from an infectious disease was twenty times lower in 1980 than in 1900.

Even for Europe one should not overestimate the speed at which the new advances in medical practice took hold. On other continents, the spread of Western medicine came up against systems of indigenous knowledge and practice; where these did not exist in written form, as in Africa, they commanded little respect from either native or European representatives of modern medicine and were relegated to a trivial everyday level.
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Things were different, however, where “great traditions” met up. In Japan, where European medicine had been known even in premodern times, it began to be practiced after the middle of the century. In the Meiji period it officially replaced the Chinese medicine that had previously been dominant. In March 1868, in one of its first decrees, the new Meiji government—which contained an unusually large number of politicians with a medical background—proclaimed that Western medicine should be the only compulsory element in the training of doctors in Japan. After 1870, with the help of numerous German doctors, medical education was completely reshaped in accordance with the German model. The “old” (that is, Chinese) medicine was supposed to wither away gradually. Anyone who wished to become a licensed doctor had to pass an examination in Western medicine, but traditional doctors put up resistance. In the treatment of the commonly seen beriberi, indigenous medicine proved itself superior, partly because the disease was not a major health risk in Europe. In practice the two systems continued to coexist in a complementary relationship. Around the turn of the century, two thirds of statistically recorded doctors in Japan belonged to the traditional Chinese school.
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A knowledge transfer in the opposite direction, from Asia to Europe, had already occurred in the early modern period. Jesuit missionaries collected Chinese medical texts and herbals. Publicly disseminated reports by individual Jesuits, and especially the account published in 1727 of the Westphalian doctor Engelbert Kaempfer's trip to Japan in 1692–94, meant that Asian practices such as acupuncture or moxibustion were made known in the West. A number of Western textbooks tried to make sense of Chinese healing theories. Yet East Asian medicine did not find large-scale application in the West until the second half of the twentieth century. Unorthodox medical knowledge scarcely gains acceptance by itself. It requires a measure of intellectual receptiveness, a body of healers able to apply the new methods, patients ready to accept them, and sometimes an institutional underpinning in something like a “health system.” Even failing such tough requirements, East Asian techniques of healing never ceased to fascinate Western medical experts. The ups and downs of that fascination plot a curve of Western openness toward alternative traditions of knowledge.
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4 Mobile Perils, Old and New

The End of the Plague in the Mediterranean

Any epidemic disease poses specific challenges to a society. Each develops at its own speed and has its own victim profile and pattern of spatial distribution. Each also has its own “image,” a special significance that people attach to it. And each has its own mode of transmission, a distinctive moment of infection. Bubonic plague, a disease carried by rat fleas that was more deeply engraved than any other in the European imagination, was an Asian phenomenon in the nineteenth century. It receded from western Europe after the great surge of 1663–79, which gripped England, northern France, the Low Countries, the Rhine Valley, and Austria. The penultimate outbreak was unleashed in 1720 by a French ship returning from plague-stricken Syria; more than 100,000 people died of the disease in Provence over the next two years.
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The last major epidemic in Europe outside the Ottoman-ruled Balkans overwhelmed Hungary, Croatia, and Transylvania in 1738–42. Improved checks at major ports, as well as the Austrian military
cordon sanitaire
in the Balkans completed in the 1770s, shielded Europe from further plague imports from Asia.
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France and the Habsburg Monarchy were Europe's frontline states and therefore had the most experience; the continent owes them a major debt of gratitude for keeping it free of plague in the late modern period. An additional factor was the transition everywhere in eighteenth-century European cities from wooden and half-timbered construction to stone architecture, which meant that rats, the main carrier of plague, lost some of their habitat.
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